Pregnancy with IDDM is a high-risk case. Antenatal management should aim at keeping the patient euglycemic, early detection and treatment of maternal and fetal complications for an optimum outcome.
Patient should be managed at diabetes clinic with diabetelogist and specialist diabetes mid-wife. She should be provided with written information and leaflets about the disease and management, telephone contacts in cases of emergency. Since she has presented at 10wks gestation, she should be informed that any medical care or intervention cannot alter congenital anomalies that would have occurred in the first 4-6wks.Insulin requirements increase in early pregnancy .Pt may be admitted to achieve optimum diabetes control
Hypoglycemic episodes are common in early pregnancy. Pt and her family should be taught to recognize signs and take glucose drink or glucagons.
Insulin regimen usually followed is to give intermediate or long acting insulin with preprandial short acting insulin. Preprandial glucose is measured to ensure optimum control.
Pre-existing maternal complications should be assessed Retinopathy worsens with pregnancy. Ophthalmic assessment is done to detect any retinopathy. Renal function tests such as U&E, 24hrs urine for proteins and creatinine clearance should be done. Nephropathy carries poor prognosis. If the pt is on antihypertensive drugs, such as ACE inhibitors or B-blockers, they should be changed. ACE inhibitors are teratogenic and may cause impaired fetal renal function B-blockers cause IUGR.She can be started on Methyldopa, which is safe in pregnancy.
Serum screening in diabetics may not give accurate results. USS should be done for NT and other chromosomal anomalies and structural defects. A detailed cardiac scan should be done since the fetus is at high risk of developing cardiac anomalies. Follow up scans are done every 2-4wks for early detection of macrosomia or IUGR. If there is suspicion of IUGR, fetal well-being should be monitored by umbilical artery Doppler or regular CTG.Both macrosomic and IUGR fetuses are at risk of sudden intra uterine fetal death and may need to be monitored by hospital admission .She may even need preterm delivery to save fetus from IUFD.
Maternal complications such as pre-eclamsia, may be detected and treated early with regular and frequent antenatal follow up and monitoring of blood pressure and urine. Polyhydramnios is associated with preterm labour. Optimum glycemic control ,NSAIDs and amnioreduction may help prolong pregnancy and reduce maternal discomfort.
If blood sugar is maintained within normal limits and the fetus is growing normally vaginal delivery should the aim.Alternatively,in cases of mild macrosomia preterm delivery may be considered or caesarian section is recommended in cases with gross macrsomia.
Posted by Rani M.
The outcome can be optimised by multidisciplinary care, proper glycemic control and close surveillance for early recognition, prevention or treatment of complications.
She should be booked for antenatal care by a multidisciplinary team comprising of consultant obstetrician,physician, specialist nurses preferably in a joint clinic.
Optimum glycemic control is aimed i.e. fasting blood sugar less than 5.5mmol/l and postprandial less than 7.1mmol/l. Insulin dose may need to be increased due to increasing insulin resistance throughout pregnancy,highest between 28-32 weeks.She is asked to increase home glucose monitoring.Low sugar, low fat and high fibre diet is advocated to aid glycemic control.
Tight glycemic control inadvertently put woman at increased risk of hypoglycemia. She is advised regarding signs and symptoms of hypoglycemia and how to manage it with glucose drinks. Partner/ family are provided with glucagon kit and taught how to use it.
There is increased risk of ketoacidosis in the event of infection,use of tocolytics and corticosteroids.Therefore caution is excersied when these drugs are used in the event of threatened preterm labour. Infections are promptly treated.
Diabetics are at an increased risk of infections. M.S.U. is checked at each visit and enquires are made regarding symptoms of candidiasis or chest infections & treatted appropiately.
Ophthalmologic examination is offered at the booking and then regularly depending on the severity of retinopathy. Retinopathy may present for the first time during pregnancy or may deteriorate.Laser photocoagulation can be done during pregnancy if required.
Close vigilance is kept on B.P. for there is risk of developing hypertension and deterioration in associated complications such as nephropathy and neuropathy.Renal function are checked in each trimester.
Fetal complications are miscarriage if there is severly uncontrolled diabetes. Therefore optimum control minimises the complications. An early dating scan & anamoly scan is done and repeated at 18 weeks. Detailed cardiac scan is done as cardiac anamolies are the commonest.Serum screening test if done need to be interpretated with caution due to lower levels normally seen in diabetics.
Serial scans are done in third trimester to detect macrosomia and also for polyhydramnios.
Induction of labour is done at 38 weeks or 38-40 weeks as per hospital protocol. This is due to increase in unexplained intrauterine deaths after 36 weeks and risk of macrosomia.
During labour insulin is given via infusion pump and regular glucose monitoring is done, doses are adjusted as per sliding scale. Aim is to keep blood sugar between 4-8 mmol/l Intrapartum hyperglycemia is a risk factor for neonatal hypoglycemia. Continuos electronic fetal monitoring is done. Partogram charting is required for early detection of slow progress in labour. Operative delivery is avoided due to risk of shoulder dystocia. Regular shoulder dystocia drills and labour ward protocols for shoulder dystocia management are essential.Senior obstetrician should attend the delivery. Effective analgesia should be offered to maintain homeostatic control.
Baby is given early feeds. Neonatologist examines the baby for birth trauma, congenital anamolies and baby is observed for metabolic complications such as hypoglycemia, hyper bilirubinemia, polycythemia etc.
Post partum there is risk of hypoglycemia as insulin requirements fall rapidly. Insulin doses are reduced to prepregnancy doses or reduced by 25% if woman intends to breast feed.
Regular audits should be done to know areas where improvements are required and for making recomendations.
Continuos participation of woman in her management and antenatal care is essential for good compliance and optimal outcome
